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Military Nursing Research

Military nursing research is defined as nursing research with direct relevance to the military environment. Its objectives are to advance the practice of military nursing in support of mission readiness and deployment; to enhance nursing delivery systems and processes to improve clinical outcomes during peacetime, wartime, and humanitarian relief missions; to improve the health status and quality of life of military personnel and their beneficiaries; and to provide optimal nursing care in settings throughout the world. The fundamental purpose of military nursing research is to further the knowledge of military nurses and to enhance their capacity to provide quality nursing care for the armed forces.

At the time of this writing, the TriService Nursing Research Program (TSNR Program) is starting its fifth year of funding research proposals by military nurses for military personnel and their beneficiaries. The program has received increasing financial support from the U.S. Congress, from a $1 million appropriation in 1992 to $5 million in 1995 and again in 1996.

Nursing Research Resources in the Military

The TSNR Program functions in an environment in which the resources for conducting military nursing research differ across the three services, but the Army, Navy, and Air Force Nurse Corps have each demonstrated their support for nursing research.

To understand the environment of military nursing research better, the Institute of Medicine committee examined official positions of the military



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--> 3 Military Nursing Research Military nursing research is defined as nursing research with direct relevance to the military environment. Its objectives are to advance the practice of military nursing in support of mission readiness and deployment; to enhance nursing delivery systems and processes to improve clinical outcomes during peacetime, wartime, and humanitarian relief missions; to improve the health status and quality of life of military personnel and their beneficiaries; and to provide optimal nursing care in settings throughout the world. The fundamental purpose of military nursing research is to further the knowledge of military nurses and to enhance their capacity to provide quality nursing care for the armed forces. At the time of this writing, the TriService Nursing Research Program (TSNR Program) is starting its fifth year of funding research proposals by military nurses for military personnel and their beneficiaries. The program has received increasing financial support from the U.S. Congress, from a $1 million appropriation in 1992 to $5 million in 1995 and again in 1996. Nursing Research Resources in the Military The TSNR Program functions in an environment in which the resources for conducting military nursing research differ across the three services, but the Army, Navy, and Air Force Nurse Corps have each demonstrated their support for nursing research. To understand the environment of military nursing research better, the Institute of Medicine committee examined official positions of the military

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--> Nurse Corps concerning military nursing research, information about positions that call for doctorally prepared nurses, the supply of doctorally prepared nurses, the number of nurses enrolled in advanced degree programs, and major resources for facilitating nursing research in each of the military services. Policy Statements Supporting Military Nursing Research The following excerpts from policy statements indicate the support of the military Nurse Corps for nursing research. Army The Army Nurse Corps (ANC, 1981) established its policy statement on the value of nursing research to the Corps in 1981; excerpts from this statement follow: Nursing research is ethical, responsible and relevant to nursing practice. . . . The primary task of nursing research is to advance nursing practice and improve patient care. The nursing profession, and hence the Army Nurse Corps officer, has an obligation to contribute to nursing science by conducting or participating in nursing research as well as research from other disciplines. The professional Army nurse has a personal responsibility to deal effectively with ethical issues and to be informed about pertinent legal parameters of practitioner–research relationships to subjects with respect to human rights. There is a coexisting responsibility of the ANC in a corporate sense to uphold the ethical and legal aspects of research. . . . Research is the foundation of our practice discipline. To retain a credible professional posture and sustain accountability for our professional practice, the knowledge generated through research is essential. . . . The development of knowledge through research is essential for accountability of the profession to our patients and to the larger military organization. Navy The Navy Nurse Corps (1993) demonstrated a commitment to increased nursing research in its strategic plan, which was first published in 1993: Our practice of nursing will be customer-focused and research-based.

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--> The Navy Nurse Corps will support research as integral to nursing practice and health care delivery. We will invest in, conduct, apply, and publish research. We will validate the efficacy of nursing intervention, procedures, and techniques through research. We will use research findings to measure patient outcomes and determine the cost-effectiveness of nursing practice. Our nursing practice takes place within a dynamic health care system and is influenced by professional standards, mission-specific requirements, and research. Air Force The Air Force adopted a policy of support for nursing research within its ranks. A recent nursing operations manual (U.S. Air Force, 1994) includes the following excerpts from Air Force Instruction 46-101 in its outline of the responsibilities of a nurse executive: to ''coordinate and apply nursing research activities, protocols, or findings within the medical treatment facility'' and to "promote research throughout the facility." Clinical nurses have the opportunity to: "participate in research studies." The Total Nurse Force Strategic Plan (Col. Nina Rhoton, USAF, NC, Professional Nursing Programs, Office of the Surgeon General, personal communication, 1996) includes a goal of fostering and supporting nursing research. Positions Calling for Doctorally Prepared Nurses The number of approved positions for doctorally prepared nurses differs substantially among the three services, as indicated below. Army Currently, the Army has 54 approved positions that call for doctorally prepared nurses to occupy roles in research, clinical practice, administration, or education; and it has 36 doctorally prepared nurses on active duty. Navy In 1987, the Navy Nurse Corps conducted a review of all billets (approved positions) worldwide and identified 11 billets that specify doctorally prepared

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--> nurses. The Navy Nurse Corps currently has eight active-duty nurses with this educational preparation. Billets include clinical nurse researchers and directors of such programs as anesthesia nursing and education. Research billets are located at the National Naval Medical Center, Bethesda, Maryland; the Naval Medical Centers in Portsmouth, Virginia, and San Diego, California; and the U.S. Naval Hospital in Okinawa, Japan. Air Force U.S. Air Force currently has two billets requiring doctorally prepared nurses: the director of nursing research at the Graduate School of Nursing at the Uniformed Services University of the Health Sciences (Bethesda, Maryland) and the senior health service researcher at the Air Force Surgeon General's Office at Bolling Air Force Base in Washington, D.C. There is one billet, currently unfilled, as senior clinical coordinator for students in the second year of the U.S. Air Force graduate program conducted with Texas Wesleyan University in Fort Worth, Texas, and a recently approved billet for a doctorally prepared nurse in the graduate education program at Uniformed Services University of the Health Sciences. There are 12 active-duty nurse officers with the earned doctorate. Master's and Doctorally Prepared Nurses As summarized in Table 3-1, there are currently 3,125 master's-level and 56 doctorally prepared nurses out of approximately 12,000 active-duty nurses in the three military services combined. Thus, approximately 25 percent of active-duty military nurses have at least a master's degree, and approximately 0.5 percent have an earned doctorate. By comparison, approximately 10 percent of civilian nurses have a master's degree or greater.1 Although the percentage of master's-level nurses in the military is higher than that in the civilian population, both the percentage and the total number of doctorally prepared military nurses are small in relation to the many research questions confronting military nurses. As described below, not all of the active-duty doctorally prepared military nurses are involved in research. The majority (196) of the doctorally prepared military nurses are reservists (see Table 3-1). 1   That is 173,900 out of 1,764,500 fully employed registered nurses (estimated active supply of total registered nurses and education preparation as of December 31, 1994, Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services).

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--> TABLE 3-1 Total Military Nurse Corps Officers, by Component, Educational Preparation, and Service   On Active Duty   Total Doctorally Prepared Nurse Corps Officers Service Total Nurse Corps Officersa Total Master's Prepared Nurse Corps Officers Reserve Component Officersa Active Reserveb Army 4,100 1,270 14,197 36 75 Navyc 3,309 623 1,900 8 38 Air Force 4,853 1,232 3,361 12 83 Total 12,262 3,125 16,987 56 196 a Statistics from the respective offices of the chief or directors of Nurse Corps or of the reserve component. b Includes National Guard. c Includes Marine Corps. Errata P. 35, Table 3-1: the total value for "Reserve Component Officers" should be 19,458 not 16,987.

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--> Each of the military Nurse Corps has supported advanced educational preparation of selected active-duty nurse officers. Between 1990 and 1995, the Army Nurse Corps supported doctoral education for 24 Nurse Corps officers, the Navy Nurse Corps did so for 11, and the Air Force Nurse Corps for 7. Although this support for advanced education has been relatively consistent over the period examined, the net gain in the number of doctorally prepared Nurse Corps officers is low, primarily due to retirement. Facilities for Research Army The Nursing Research Service at Walter Reed Army Medical Center (Walter Reed AMC) has four approved positions for doctorally prepared active-duty nurses whose primary duty responsibilities are to manage or conduct nursing research projects and to mentor new nurse investigators. Recognized as the primary site within the Army for developing new nurse researchers, the service supports the implementation, dissemination, and utilization of research throughout the Department of Nursing. Madigan Army Medical Center (Madigan AMC) in Tacoma, Washington, also has a Nursing Research Service, which combines military and civilian nurse research staff. This service supports the Madigan Department of Nursing in the implementation, dissemination, and utilization of nursing research. In March 1992, the role of regional nursing research coordinator was created to decentralize the Army's nursing research structure (Kennedy, 1994). Regional sites include Walter Reed AMC; Madigan AMC; Tripler Army Medical Center in Honolulu, Hawaii; Brooke Army Medical Center in San Antonio, Texas; William Beaumont Army Medical Center in El Paso, Texas; Fitzsimmons Army Medical Center in Denver, Colorado; and Eisenhower Army Medical Center in Augusta, Georgia. The nursing research consultant integrates, facilitates, and guides the work of regional nursing research coordinators. In addition, the Nursing Research Advisory Board, which meets yearly or biennially, as needed, provides global oversight for research in Army Nurse Corps. The regional nursing research coordinators are doctorally prepared nurse officers who serve in this capacity in addition to their assigned position, which ideally has a research focus.

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--> Navy At present, there are no specific Navy facilities or commands designated as centers of research, nor is there one specific Navy-wide nursing research program. However, the Navy Nurse Corps expresses belief in the future of doctorally prepared nurses in the Navy Nurse Corps. As the inventory of master's and doctorally prepared nurse researchers grows, the Navy plans to assign two doctorally prepared nurses to selected tertiary care facilities, including the National Naval Medical Center, Bethesda, Maryland, and the Naval Medical Centers in San Diego, California, and Portsmouth, Virginia. These billets will provide novice Navy nurse researchers with a supportive environment and facilitate more collegial and collaborative relationships within the Navy and among the services. Possible future assignments may include service as directors of clinical investigation departments, a headquarter's position to involve the Clinical Investigation Program throughout the Navy, assignment to various policy review and development positions within the Navy or the Department of Defense (DOD), or service as regional geographic coordinators. Air Force The Air Force currently has no formalized centers of research. Nursing research committees exist in various Air Force medical centers, and nurses hold membership on multidisciplinary research committees at some treatment facilities. Also, nurses participate in institutional reviews of clinical research. The Air Force is in the process of coordinating the assignment of doctorally prepared nurses to its four Clinical Investigation Divisions, which operate at the largest Air Force medical centers: Andrews Air Force Base in Washington, D.C.; Travis Air Force Base in California; Wright-Patterson Air Force Base in Ohio; and Wilford Hall in San Antonio, Texas. Published and Current Research Relevant to Military Nursing Examination of the body of published works in a field can help to identify strengths and areas needing increased attention. Ongoing civilian nursing research is likely to have considerable application to military nursing, especially with regard to improving nursing care and nursing care systems for beneficiaries of service members. Therefore, the committee conducted extensive literature searches to identify published works on military nursing research and targeted searches to identify studies being conducted as part of major programs of

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--> ongoing civilian nursing research. Relevant citations from these searches appear in the companion publication to this report, Military Nursing Research: Bibliographies (IOM, 1996), along with annotations to the extent that abstracts were available. The search results are discussed briefly below. Published Military Nursing Research Search Strategy Seven databases served as the source of research citations and abstracts of the published scientific literature directly applicable to military nursing, as shown in Table 3-2. Each database served as a unique source of relevant information, with distinct and discrete emphasis for the study. For the databases MedLINE, Current Information in Nursing and Allied Health Literature (CINAHL), Health Services/Technology Assessment Research (H-STAR), PsycInfo, and National Technical Information Service (NTIS), the following search strategy was used: Descriptor [nursing] and any of the following terms, anywhere in the record: [aerospace or air evacuation or air force or armed forces or army or champus or combat or deployment or depmed or desert shield or desert storm or echelons of care or field hospital or field nursing or flight or gulf war or medevac or military or military dependent or national guard or naval-medicine or navy or posttraumatic or readiness or recruit or reserves or retiree or service member to telemedicine or transport or tricare or Vietnam] The search strategy for the database Technical Reports (TR) in the Defense Technical Information Center (DTIC) Defense Research On-line System (DROLS) and Dissertation Abstracts used the descriptor term [nursing] and the free text term [military] only. These strategies intentionally limited the search to articles that deal with nursing care of military populations and other nursing topics with either a military focus or a focus on a subject highly relevant to the military, such as flight nursing or telemedicine. Information retrieved in the search of published works was, in many cases, different from areas of research funded by the TSNR Program. The committee recognizes that if some of the funded studies had already resulted in publications, several might not have been uncovered by employing the specified search strategies, especially those that did not use military study populations.

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--> TABLE 3-2 Databases Searched for Published Research Relevant to Military Nursing Database Years Searched MedLINE 1966–1995 Current Information in Nursing and Allied Health Literature (CINAHL) 1983–1995 Health Services/Technology Assessment Research (H-STAR) 1975–1995 PsycInfo 1967–1995 National Technical Information Service (NTIS) 1964–1995 Technical Reports (TR) in Defense Technical Information Center (DTIC) Defense Research On-line System (DROLS) 1985–1995 Dissertation Abstracts 1977–1995 Results of Literature Searches Having access only to citations and abstracts (and sometimes only to citations), committee members did not assess the quality of the studies retrieved in the literature searches. Neither did they explore all aspects of a specific topic as would be done if they were preparing a research proposal. Instead, they focused on the number and range of studies in an area; the approaches used in addressing the topic; the extent to which citations were likely to represent peer-reviewed research articles; and the extent to which cultural background was considered, if applicable. The bibliographies produced from the search results (IOM, 1996) include citations to some studies that committee members considered might be seriously flawed. Such citations are included because they are a part of the information processed. No indications of quality are to be assumed. Of the more than 2,000 citations retrieved from the databases MedLINE, CINAHL, H-STAR, and PsycInfo, 161 were identified by the committee as research reports or reviews relevant to military nursing. Many of these did not address military populations. Citations and abstracts for research articles identified through search of NTIS and Technical Reports in DROLS (DTIC) were examined separately since a majority have limited distribution and have not undergone the peer review that is typical for scientific journals. From the combined retrieved citations for technical reports, 150 were identified as obvious research reports, a large percentage of which were master's theses. The search of Dissertation Abstracts yielded 73 relevant abstracts, 51 of which were for doctoral dissertations. All of these dealt, at least in part, with military nurses or with patients who were current or retired service members or their dependents. An additional 15 dissertations addressing military topics (titles only) were uncovered in the search of CINAHL and PsycInfo. The committee

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--> categorized the research reports retrieved from the search of journals, technical reports, and dissertations separately into 10 topic areas, as shown in Table 3-3. It is clear that health services planning or health services and resources is the topic area that has been studied most extensively overall. This category covers many subjects, including a number of published research articles on topics related to aeromedical evacuation, technical reports on medical supply systems, and such service-specific topics as tasks of the shipboard independent duty hospital corpsman. Nurses' career development has also received much attention, with recruitment and retention of personnel major topics of concern. After military nursing history (48 titles), stress and coping is the topic with the most titles (25) obtained from the search of the databases covering professional journals, but this number includes many dissertation abstracts retrieved from PsycInfo. A number of these stress and coping articles deal with posttraumatic stress. Few articles address cultural topics related to military nursing. References to historical articles appear separately in Military Nursing Research: Bibliographies (IOM, 1996). In addition to the above sources of research articles, each of the three military services has these and dissertations on file at selected repositories. For instance, there are 192 Navy Nurse Corps theses and dissertations on file at the Stitt Medical Library in Bethesda, Maryland; their titles appear in the TABLE 3-3 Categorization of Military Nursing Research Articles Retrieved from Database Searches for Journal Articles, Technical Reports, and Dissertation Abstracts Topic Journal Articles (n = 161) Technical Reports (n = 150) Dissertation Abstracts (n = 73) Nurses' career development 22 31 15 Military nursing history 48 6 14 Patient risk factors 1 3 15 Stress and coping 25 5 10 Health services planning or health services and resources 24 53 10 Nursing care practice/procedures 16 22 5 Nurses' cognitive style/learning principles 2 8 1 Patient care outcomes 6 8 2 Adverse drug effects 0 1 1 Nurse and/or patient perceptions 17 15 0 Errata P. 40, Table 3-3: in the "Technical Reports" column, the value for "Health services planning" should be 54 (not 53), the value for ''Nursing care practice/procedures" should be 21 (not 22), and the value for ''Patient care outcomes" should be 6 (not 8).

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--> companion bibliography. The Air Force's Air University Library at Maxwell Air Force Base, Alabama, has approximately 100 theses covering nursing research conducted by members of the Air Force. Although the Army does not require a formal filing of dissertations, there are dissertations on file at Walter Reed AMC library. All Army theses and dissertations are abstracted at the Nursing Research Service at the Walter Reed AMC. The committee searched specifically for articles that covered racial and ethnic background. Several of the articles on recruitment and retention did (Kocher and Thomas, 1994; Shigley, 1988; Simpson, 1992; Thomas et al., 1988, 1989). Smith (1993) addressed language and cultural barriers during Operation Desert Shield/Desert Storm. Erickson-Owens and Zdenek (1988) focused on removing cultural barriers to care during childbearing by Philipino, Korean, and Mexican-American mothers. The committee found no other articles that clearly focused both on the military and on cultural issues. The published literature contains many nonresearch articles relating to the history of military nursing, anecdotal reports of challenging aspects of nursing care, and articles that address recruitment and job satisfaction. The retrieved titles and abstracts (and the articles themselves) may stimulate identification of potentially fruitful areas for military nursing research. To this end, selected titles are included in the companion publication to this report, Military Nursing Research: Bibliographies (IOM, 1996). Current Civilian Nursing Research To avoid making recommendations that would duplicate ongoing research, the committee examined results of searches of databases providing information on two major nursing research programs: those conducted by (1) the National Institute for Nursing Research (NINR) and (2) the Department of Veterans Affairs. Brief descriptions of these programs follow, along with brief summaries of the search results. The companion publication Military Nursing Research: Bibliographies (IOM, 1996) gives listings of the studies that were retrieved and annotations (where abstracts were available). National Institute of Nursing Research According to its mission statement, the NINR (1995) seeks to reduce the burden of illness and disability by understanding and easing the effects of acute and chronic illness; to improve health-related quality of life by preventing or delaying onset of disease or slowing its progression; to establish better approaches to promoting health and preventing disease; and to improve

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--> clinical environments by testing interventions that influence patient health outcomes and reduce costs and demand for care. Under this broad mandate, NINR launched its first National Nursing Research Agenda in 1987 by implementing seven research priorities (NINR, 1993) designed to provide a structure for selecting scientific opportunities and initiatives; these priorities were low birth weight: mothers and infants; HIV (human immunodeficiency virus infection): prevention and cure; long-term care for older adults; symptom management: pain; nursing informatics: enhancing patient care; health promotion for older children and adolescents; and technology dependence across the life span. In 1992, the National Nursing Research Agenda (NINR, 1993) established five more research priorities designed to guide a portion of NINR funding from 1995 through 1999: community-based nursing models; effectiveness of nursing interventions in HIV/AIDS; cognitive impairment; living with chronic illness; and biobehavioral factors related to immunocompetence. The search of the database CRISP identified 317 studies being conducted by NINR, most of which could be categorized in the areas described above. None of these has a study focus that is related specifically to military nursing, but management of pain, nursing informatics, and biobehavioral factors related to immunocompetence would have direct applicability to service members and their beneficiaries alike. Nursing Research Initiative The Department of Veterans Affairs began a small but similar program of nursing research in 1993 called the Nursing Research Initiative. This program is designed to "(1) encourage new research projects pertaining to nursing topics; and, (2) expand the pool of nurse investigators within the VA health care system" (U.S. Department of Veterans Affairs, 1995).

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--> A search of the database Federal Research in Progress identified current nursing research projects funded by the Department of Veterans Affairs, including one that was not initiated. A broad scope of topics was covered, including responses to touch, various aspects of mental disorders, biological rhythms in intensive care patients, roles and competencies of nurses, and comparative studies of selected nursing techniques. Studies Funded by the Triservice Nursing Research Program The committee closely examined the content of abstracts of the 77 research proposals that were funded by the TSNR Program during the fiscal year (FY) 1992 through FY 1995. References for these studies are listed in Appendix D, and the complete abstracts are given in the companion publication Military Nursing Research: Bibliographies (IOM, 1996). To develop an understanding of the scope and types of studies that received funding, the abstracts were analyzed in two ways: by examining (1) the distribution of grants among priority areas identified by the TSNR Program in its annual Request for Proposals and (2) characteristics of the studies. Because military populations are very diverse culturally, the committee also examined the abstracts for attention to this topic. Distribution of TSNR Program Awards by Priority Areas Priority areas for the TSNR Program are listed in Table 3-4 for 1992 and 1993, in Table 3-5 for 1994, and in Table 3-6 for 1995, along with the number of projects and total funding in each priority area. The committee categorized the abstracts since this information was not available from the program. Over the first 2 years of the program, with $1 million in funding during FY 1992 and $2 million in FY 1993, grants were distributed unevenly among the five priority areas, with two areas receiving no awards (Table 3-4). The major area funded was health care delivery. Seven grants out of 30 (totaling nearly 20 percent of the total budget of $3 million) appeared to the committee to fall outside priority areas. In 1994, with its budget increased to $3 million, the TSNR Program listed 10 priority areas and specified that research applying to the military would be given highest priority. As shown in Table 3-5, the priority area "Evaluation of nursing/women's health programs/deployment" received the largest dollar value of the awards, followed by the area "Application of clinical nursing to a military environment." The committee's categorization indicated that 4 of the 10 priority areas designated in 1994 received no grants and that 25 percent of the awards,

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--> TABLE 3-4 TriService Nursing Research Program Grant Awards, FY 1992–1993, by Priority Area, Total Number of Awards, and Amounts   Number of Grants Funded     Priority Areaa 1992 1993 Total Grants Awarded Total Amount Awarded ($) Health care delivery 5 13 18 1,522,586 Family stress related to wartime separation/injury 1 3 4 475,417 Access to health care 1 0 1 10,589 Child abuse 0 0 0 0 Lead poisoning 0 0 0 0 Subtotal 7 16 23 2,008,592 Other: Health of military personnel 1 6 7 468,349 Total 8 22 30 2,477,503 a Priority areas were identified in the 1992 and 1993 Requests for Proposals. The committee assigned each grant to one priority area. Errata P. 44, Table 3-4: in the "Total Amount Awarded" column, the "Total" value should be $2,476,941 not $2,477,503. TABLE 3-5 TriService Nursing Research Program Grant Awards, FY 1994, by Priority Area, Number of Awards, and Amounts Priority Areaa Total Grants Awarded Total Amount Awarded ($) Application of clinical nursing to a military environment 5 689,743 Nursing interventions related to injury, trauma, burns, wound healing, evacuation, and long-term sequelae 5 142,677 Evaluation of nursing/women's health programs/deployment issues 4 812,612 Nursing interventions for military-related stress/adverse conditions 3 255,496 Nontraditional symptom management 1 355,225 Ethical/clinical decision making in a military nursing environment 1 100,880 Application of nursing interventions to field conditions 0 0 Technology applications to support nursing care in the field 0 0 Emergency nursing care for acute illness and trauma 0 0 Military service or deployment and spousal/child abuse, preventive health care, and wellness promotion 0 0 Subtotal 19 2,356,633 Other (health adviser program evaluation, history of military nursing, pediatric care program, and military family health) 5 660,860 Total 24 3,017,493 a Priority areas were identified in the 1994 Request for Proposals. The committee assigned each grant to one priority area.

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--> totaling $660,000, went to study topics (e.g., history of military nursing, health advisory program evaluation) outside the TSNR Program's priority areas. The priority areas changed again in 1995, and the TSNR Program appropriation was increased to $5 million. Table 3-6 shows that of the 10 priority areas, "Women's health issues" and "Prevention of complications associated with battle injuries" received the highest number of awards and total funding. The committee's synthesis of topic categories for all funding for the years 1992–1995 is presented in Table 3-7. After reviewing the data in this configuration, several conclusions were drawn. The delivery of military health care is the category that has received most funding from the TSNR Program. This is important in that military health care is going through a number of transitions based on the need for cost containment in health care, access to health care issues, and a more peacetime health care service. For example, the new military managed care system known as Tricare has introduced a major change in health care delivery to beneficiaries. Studies that address women's health issues have received the second-most TSNR Program funding. Since the proportion of women in the military is TABLE 3-6 TriService Nursing Research Program Grant Awards, FY 1995, by Priority Area, Number of Awards, and Amounts Priority Areaa Total Grants Awarded Total Amount Awarded ($) Women's health issues 6 1,768,738 Prevention of complications associated with battle injuries 6 1,038,333 Disease prevention/wellness 3 280,815 Readiness/deployability 3 166,826 Case management 2 243,844 Operational issues 1 163,526 Spousal/child abuse 0 0 Home care 0 0 Transportation of patients 0 0 Training of medevac personnel 0 0 Subtotal 21 3,662,082 Other (Air Force nursing history, low birth weight infants) 2 278,889 Total 23 3,940,971 a Priority areas were identified in the 1995 Request for Proposals. The committee assigned each grant to one priority area.

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--> TABLE 3-7 Synthesis of TriService Nursing Research Program Grant Awards, FY 1992–1995, by Research Category,a Number of Awards, and Amounts   Number     Category 1992 1993 1994 1995 Total Grants Awarded Total Amount Awarded ($) Delivery of military health care 5 12 7 5 26 3,023,443 Women's health 1 3 3 5 12 2,497,251 Health of military personnel, readiness/deployment 1 3 3 5 12 964,002 Nursing care interventions under field conditions 0 0 5 6 11 1,536,235 Health of military family 1 3 3 3 10 1,370,135 History of military nursing 0 1 2 1 4 223,361 Other 0 0 1 1 2 70,509 Total 8 22 24 23 77 9,684,936 a Identification of research categories and assignment of projects to those categories were performed by the committee. Errata P. 46, Table 3-7: in the "1995" column, the value for "Delivery of military health care" should be 2 not 5. growing and relatively few studies have been conducted on this population (IOM, 1995), strong support in this area is easily justified. Since 1994, 11 studies of nursing care under field conditions in the military have been funded by the TSNR Program. This topic is of obvious military relevance, and further work in this area should be encouraged through the funding of carefully selected studies. Studies concerning the health of military personnel, including their readiness for deployment, have been funded each year, and this category ranks fourth in funds awarded by the program. Substantial support in this area is desirable since one of the goals of the program is to develop nursing knowledge that is useful in the military setting. Study Characteristics of TSNR Program Grants As a further analysis of funded grants, the committee also categorized the 77 funded TSNR Program projects under six design parameters: (1) target population, (2) study population, (3) study design, (4) environment, (5) research topic, and (6) primary exposure. As can be seen in Table 3-8, this categorization

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--> TABLE 3-8 Numbers of Funded TriService Nursing Research Program Projects by Study Characteristics Characteristic Target populations Number of Funded Studiesa Characteristic Environment Number of Funded Studiesa Military nurses 20 Inpatient 24 Families of military nurses 1 Outpatient 26 Other military beneficiaries 23 Combat setting 0 General (nonmilitary) 30 Normal working/living setting 19 Other 3 Laboratory 4 Study populations   Other 4 Families 9 Research topic   Infants/prenatal 5 Trauma/injury 13 Children/adolescents 2 Infectious disease 2 Adults 53 Noninfectious disease/condition 13 Elderly 0 Perinatal/reproductive 5 Animal 5 General health 5 None 3 Health care utility and/or access 9 Study design   Psychosocial/behavioral 23 Experimental/randomized 22 Other 7 Quasiexperimental/nonrandomized 16 Primary exposure   Observational (crosssectional) 22 Clinical health care intervention 39 Observational (longitudinal) 6 Psychosocial/behavioral 26 Qualitative 5 Environmental 4 Historical 6 Sociodemographic 0     Other 8 a Each of the 77 studies was assigned to only one subcategory per characteristic. Thus, the total for each characteristic is 77.

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--> of funded grants yields some interesting results. For example, although these studies were being conducted by military personnel, almost 40 percent focused on nonmilitary target populations. However, more than 25 percent focused specifically on military nurses. The largest single grouping (70 percent) focused on adults, whereas 12 percent focused on family issues. Nearly half were experimental or quasi experimental in design. The most common topic area was psychosocial/behavioral research (30 percent). Trauma/injury accounted for 17 percent, and infectious diseases, 3 percent. The committee found evidence of attention to racial, ethnic, or cultural influences or issues in four studies funded by the TSNR Program (DeCasares, 1993; Giger, 1995; Johnson, 1995; Stotts, 1994), ranging from electrical stimulation and foot skin perfusion in black and white individuals with diabetes mellitus (Stotts, 1994) to coronary heart disease risk factors and behavioral risk reduction strategies for premenopausal African-American women (Giger, 1995). Other studies funded by the TSNR Program may address cultural issues, but they cannot be identified from review of the abstracts. The committee recommends that the TSNR Program develop a system to categorize grants by research priorities and by other characteristics, such as those in Table 3-8, as part of its evaluation plan. These data could then be retrieved quickly to respond to inquiries. Research Dissemination and Utilization The dissemination and utilization of research are integral aspects of the research process. In the field of nursing, the dissemination of nursing research results has already yielded many health benefits and cost savings for the public. Examples are provided by programs of research reported in the Annual Review of Nursing Research that have resulted in beneficial protocols: protocols that serve to protect battered women and their children (Campbell and Parker, 1992); endotracheal suctioning protocols that avoid adverse side effects such as hypoxia, mucosal trauma, and bronchospasm (Stone and Turner, 1990); protocols for inspiratory muscle training to improve functional status of the chronically ill (Kim, 1988); and protocols to manage acute pain, permit the reduced use of opiates, and minimize common opiate side effects (Hegyvary, 1993). Military nurse researchers have a history of presenting research findings at conferences, especially those sponsored by the military. However, the committee found no articles that dealt with research utilization in military settings. In the civilian nursing research literature, findings related to a number of nursing interventions, such as those listed above, would have direct application and merit evaluation for field conditions or other settings unique to the military.

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--> Summary The Army, Navy, and Air Force Nurse Corps each support the integral role of nursing research as the basis for nursing practice. Resources for nursing research differ among the military services, but each corps is seeking to strengthen its research environment. The TSNR Program is one mechanism to accomplish this. Review of citations and abstracts for peer-reviewed articles related to military nursing research indicates a broad array of research topics but a relatively small number of studies. Most of the relevant research reports that actually address military nursing do not appear in scientific journals. The military services have paid close attention to historical lessons related to nursing research, and the TSNR Program has allowed further work in this area. The TSNR Program's $9.7 million portfolio of 77 studies includes a wide range of topics, with the greatest proportion of awards and dollars given to studies dealing with the delivery of military health care. References ANC (Army Nurse Corps). 1981. Policy Statement on the Value of Nursing Research to the ANC. Washington, DC: U.S. Army. Campbell, JC, and B Parker. 1992. Battered women and their children. Annu. Rev. Nurs. Res. 10:77-94.* DeCasares, E. 1993. Army Women's Breast Cancer Risk. DeWitt Army Hospital, Fort Belvoir, VA. Erickson-Owens, DA, and RM Zdenek. 1988. Removing Cultural Barriers to Care During Childbearing: A Continuing Education Module, Master's thesis. Air Force Institute of Technology, Wright-Patterson Air Force Base, OH. AFIT/CI/NR-88-94. Giger, JN. 1995. Behavioral Risk Reduction Strategies for Chronic Indicators and High Risk Factors for Premenopausal African-American Women (25-40) with Coronary Heart Disease. University of Alabama at Birmingham.* Hegyvary, ST. 1993. Patient care outcomes related to management of symptoms. Annu. Rev. Nurs. Res. 8:27-50. IOM (Institute of Medicine). 1995. Recommendations for Research on the Health of Military Women. Committee on Defense Women's Health Research. Washington, DC: National Academy Press. IOM (Institute of Medicine). 1996. Military Nursing Research: Bibliographies. Committee on Military Nursing Research. Washington, DC: National Academy Press. Johnson, AD. 1995. The Effects of Culturally Sensitive Messages and Health Beliefs. University of Texas, San Antonio, TX.* *   TriService Nursing Research Program Grant. See companion publication, Military Nursing Research: Bibliographies (IOM, 1996) for abstracts of these studies.

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--> Kennedy, TE. 1994. The evolution of nursing research in the Army Nurse Corps. Mil. Med. 159:680-683. Kim, MJ. 1988. Physiologic responses in health and illness: An overview. Annu. Rev. Nurs. Res. 6:79-104. Kocher, KM, and GW Thomas. 1994. Retaining Army nurses: A longitudinal model. Res. Nurs. Health 17(1):59-65. Navy Nurse Corps. 1993. Navy Nurse Corps Strategic Plan. Charting New Horizons. Washington, DC: Department of the Navy. NINR (National Institute of Nursing Research). 1993. National Nursing Research Agenda: Setting Nursing Research Priorities. Bethesda, MD: National Institutes of Health. NINR (National Institute of Nursing Research). 1995. Mission Statement. Bethesda, MD: National Institutes of Health. Shigley, E. 1988. Analysis of Factors Affecting the Career Plans of Military Nurses, Master's thesis. Naval Postgraduate School, Monterey, CA. Simpson, PF. 1992. Promotion Opportunities of Minorities to the Controlled Grades in the Navy Nurse Corps, Master's thesis. Naval Postgraduate School, Monterey, CA. Smith, BJ. 1993. The nurse executive in Operation Desert Shield/Desert Storm. Nurs. Manage. 24(1):68-70. Stone, KS, and B Turner. 1990. Endotracheal Suctioning. Annu. Rev. Nurs. Res. 8:27-50. Stotts, NA. 1994. Electrical Stimulation and Diabetic Foot Skin Perfusion. University of California-San Francisco.* Thomas, GW, K Kocher, TP Moore, and BJ Roberts. 1988. U.S. Army Nurse Membership, Accession and Loss Profiles (1987). Volume 1, Reserves. Final report. Naval Postgraduate School, Monterey, CA. NPS-54-88-018-VOL-1. Thomas, GW, K Kocher, and BJ Roberts. 1989. U.S. Army Nurse Membership, Accession and Loss Profiles (1987). Volume 2. Active Duty. Final report. Naval Postgraduate School, Monterey, CA. NPS-54-89-10. U.S. Air Force. 1994. Nursing Operations. Washington, DC: Department of the Air Force. U.S. Department of Veterans Affairs. 1995. Research and Development Information Letter. Washington, DC: Veterans Health Administration.